The Curious Journey of a Psychology Intern

This is a book review by guest author, Merle Molofsky, a psychoanalyst, poet, playwright and educator in New York City.

"MADMAN: Strange Adventures of a Psychology Intern," by John Suler.

John Suler, Professor of Psychology at Rider University, who has written three other books about psychology, psychoanalysis, and Eastern religion, has written a novel that presents us with a breathtakingly accurate depiction of the challenges and disturbances facing psychology interns working in a psychiatric hospital short-term care inpatient unit. Why “breathtakingly accurate”? Because his focus is on the inner life of Thomas Holden, a clinical psychologist whose first person narrative captures the perspective and voice of a young, idealistic, hardworking novice lost in the bewildering labyrinths of hospital politics, professional competitiveness, frustratingly difficult and heartbreaking inmates, and his own intense conflicts.

Anxious, sleep-deprived, curious, perplexed, and charmingly open-minded, Thomas Holden encounters situation after situation for which his education hasn’t quite prepared him, because clinical training does not necessarily prepare anyone for the pathology of their colleagues and institutions.

Accomplished writers choose their characters’ names carefully, intending to evoke cultural associations. Some names are obvious choices: a character named “Joy” could be a delight, or, ironically, depressed, or a narcissistic extension of her parents. Other names are not so obvious. I have definite associations to the name “Thomas Holden,” but I do not know if my associations match Suler’s associations and intentions. Perhaps that is all to the good, in that the names indeed can evoke literary roots without necessarily being weighed down by them. Madman can be read as part of the picaresque tradition, novels about young people discovering themselves and the world. Thomas can evoke Tom of Tom Sawyer, Holden Holden Caulfield, two of the most recognized soul-searching spiritual adventurers of American literature. Holden Caulfield had no tolerance for what he despised as “phoniness,” a trait that seemed to him to predominate in most of the human race. Tom Sawyer had a dislike for meaningless rules and regulations, constrictions that limited both physical and emotional freedom. Thomas Holden has just about enough self-awareness, maturity, and insight to avoid complete melt-down and self-destruction in the facer of “phoniness” and “meaningless rules and regulations.” His depth of understanding, his compassion, and his love of psychoanalytic thought eventually get him through the hazing and contradictions of institutional “mental health” practices. (Acknowledgment: my thanks to the Literature and Psychoanalysis Discussion Group of NPAP, facilitated by Alice Entin, as Sunday June 27, 2010 we discussed the work of J.D. Salinger, particularly Catcher in the Rye and Nine Stories, and related the work to Mark Twain’s Tom Sawyer, inspiring me to write about the name Thomas Holden in this review.)

Suler’s 27 chapter titles alert us to the themes with which he deals, the disjunctions and fantasies and dysfunctions that make up Thomas’s day by day work week and day by day daydreams. In Chapter 1, “Up,” we meet our hero, a not-so-up young man, mildly depressed, urging his broken-down Nova up a hill. Suler is hyper-sensitive to the nuance of language, the cueing of mood to word. Why would Thomas’s car be a Nova? Thomas is a newly minted psychologist, serving an internship, and of course Nova means new. And in Spanish, no va means no go. Can Thomas get his recalcitrant car up the hill, or will his worry that it will stall come true? Can he get himself jump-started? His attitude toward his internship is clearly and immediately articulated by page 2. “Internship. Doesn’t ‘intern’ mean ‘to imprison?’ We’re expected to work our butts off, all in the name of Training. It seemed more a grueling rite of passage than anything else – the establishment’s last chance to test the limits of the student’s psyche before welcoming him to the club.” And a few lines later, “Do unto others as was done unto you.”

Thomas’s introspection leads him (one page later) to say, “I love my work. I hate my work. There it is – that Old Ambivalence, the never-ending toss-up between contradictory feelings….” We become privy to all his ambivalences, his scorn of others and his self-doubt (for what is contempt if not a defense against low self-esteem); his desire to do well and his resentment that he is expected to please the powers that be, which is not necessarily his idea of doing well; his dedication to serving the patient population and his terror that he will fail them.

A significant part of Thomas’s problems is the tension among “mental health” disciplines, the rivalry and hierarchies regarding psychiatry and psychology, doctors and nurses, behaviorists and psychoanalysts. Thomas’s early musings, in Chapter 4, “Respite,” asks the question we all must ask, “What is the psychotherapist? A mirror, a shadow, a barometer, a good parent?” After explicating the possibilities, he speculates that “…the therapist at times may also need to be a real person, in fact, a substitute parent who offers what the patient needed as a child but never received….” (p. 41). His desire to be a psychotherapist, to do depth work that is psychodynamic and psychoanalytically informed, comes into conflict with the rigidities and hierarchies of institutional life. Staff meetings and case consultations become arenas of competitiveness and hostility. Rivalries are personal and professional. Could the noble calling of “psychotherapist,” in the guise of psychologist, psychoanalyst, psychiatrist, be equally prone to corruption by ambition and unconscious motivation as any other profession? Thomas discovers again and again that the professional environment in which he is embedded is a hotbed of ordinary garden variety madness.

Thomas keeps a journal, and records his feelings and thoughts about his chosen profession and his actual experiences. His relationship to his journal is a deep love relationship; he says of his journal, “It was like an old friend, my mother, my shrink, my guru – all in one.” (p. 39). His journal is his mirror, where he truly encounters himself, where he feels he truly exists, the ideal container, selfobject, good-enough object, He forms a twinship with his journal, which underscores how alone he is in the tangle of experience that is his internship, that is his life. I followed the exigencies of his journal-keeping with keen attention and bated breath, identifying with his need for self-knowledge and self-discovery through his own words, his own language, something he shares as well with his creator, the novelist John Suler, who evidently also loves language, and finds in words the nuances of meaning and associations that underly the psychoanalytic process. Young Thomas reminds me of myself when I was his age, and the many notebooks I filled (and ultimately destroyed). Somewhere in the archives of my poetry is a poem I wrote that began, “After losing three notebooks, I felt I was losing my mind.” Thomas’s notebooks indeed are his mind, and of course a key plot element is his relationship with his notebook, and the calamity of losing it. Thomas is struggling to stay sane enough, to keep a grip, to not “lose it.” His internship leads him to discover the madness of humanity, of others, of himself. Who is the “madman,” where does wisdom and sanity lie?

Perhaps one of the most engaging aspects of this beautifully crafted, engaging novel is Thomas’s encounters with patients, and the stress, anxiety, bafflement, fear, resentment, and affection he feels. Early on he is traumatized by the death in a car accident of a recently discharged patient, and the dread that perhaps her accident was a deliberate suicide, and that he therefore was incompetent and responsible.

His other patients include an old man with what appears to be senile dementia, a violent schizophrenic, and a nameless, seemingly amnesiac “John Doe” who the rest of the staff seem to believe is seriously mentally ill, and who has the benign wisdom of a Zen monk setting koans for his new (unwitting) disciple Thomas Holden.

In the always crucial (!) initial interview, Thomas asks his John Doe, “Have you forgotten what your name is?” and receives the response, “Forgotten myself, yes. And maybe you should do the same.” (p. 206). We discover along with hapless Thomas initial interview question after question being met with provocative answer after answer, provocative in that each answer questions the assumptions underlying not only the question being asked, but assumptions underlying modes of perception and concepts of reality. Sample: “Tell me about your past.” “There is no past.” And then the ultimate riff on a famous Zen koan, “”Do you want to know what my face looked like before my parents were born?”(p. 207).

In the call and response of the initial interview, John Doe leads Thomas away from the obvious and into the realm of potential awakening, away from agreed upon protocols and toward the ground of being, until perhaps in what seems like nonsense to the sincere intern Thomas trembles on an awakening, sensing the possibility of relationship, a sort of Zen koans meet Martin Buber intensity that allows Thomas to experience both his humanity and John Doe’s. Thomas tells us, “A gap had closed between us. I felt close to him, for some strange reason, like he understood – like he cared. In fact, I felt like crying.” (p. 212).

Essentially, as Suler leads Thomas through the rigors of a psychiatric hospital psychology internship, both Thomas and the reader are led to wonder about psychotherapy as science or art, to observe the staff utilizing a full range of defenses as they engage with each other, and to become self-observing and self-reflexive, so that each event is about ourselves. The internship is a realistic, totally believable Magical Mystery Tour, and the vision is mystical.

It appears that all significant reality is rooted in the mystical. Perhaps there is a truth in the Homeric insight that whom the gods seek to destroy, they first make mad, but there also is a truth in the insight that madmen are God’s beloved. During grand rounds, Rachel Finski, a patient who seems delusional and obsessional, complains bitterly and incessantly about her physical experience, that her “water is blocked,” that her water does not flow freely, that water must be able to change from solid to liquid and back again,. She fears that the fire in her belly will go out. For her, water is the essence, and if the water can’t reach her belly, the fire in her belly will go out. She obsesses about the neurochemical energy of her soul. And as she spouts her theories, the medical students are overwhelmed and lost.

Suler is versed in many mystical traditions. Rachel Finski sounds mad as a hatter, and almost as inspired as the great Persian mystical poet Rumi.

The madmen of Madman may indeed be mad, yet in their madness they also are in touch with an essential wisdom that the staff seems to need to neglect in order to maintain their equilibrium. To listen to what verges on word salad as if it had meaning can drive a believer in sanity mad.

Another wisdom teacher found in Madman is Jon, the security guard at the booth at the edge of the parking lot, who seems to have a special fondness for Thomas, perhaps recognizing Thomas as a seeker, a young man on a quest for something powerful and true, who is drawn to psychotherapy because of a mystical predilection not yet recognized and acknowledged. Jon is described as a former Berkeley philosophy student and countercultural radical, with a penchant for practical jokes that have hidden within them wry philosophical commentary.

Thomas comments early on that he never can outwit Jon, for Jon is a “master of passive-aggressive joking and one-upmanship.” Eight pages into the story, Jon sets Thomas a riddle: “What happens when you mix a dyslexic, an agnostic, and an insomniac?” Answer: “You get someone who stays up all night worrying, ‘Is there a DOG?’”

This is more than a cute gag, a spot of levity. This is what the bickering pedants on the staff need, a sense of humor that touches on the major concerns of humanity. Well, is there a DOG?

By page 114, much water under the bridge (pacem Rachel Finski and her blocked water), Jon is introducing Thomas to the I Ching, the Chinese Book of Changes that can be used in augury or as a guide for the perplexed, a wisdom instruction manual. Jon gives Thomas a brief guided tour through the theory of synchronicity, frames the concept of the I Ching as one of ambiguity leading to subjective interpretation, opposed to logical positivism. Jon insists that Thomas throw the coins used to consult the I Ching as oracle, Thomas asks of the I Ching, “How can I get over this sickness?”, meaning his cold, but lurking behind the physical is the spiritual and emotional malaise that haunts him. The hexagram he draws is hexagram 44, Kou, Coming to Meet. The hexagram is sketchily explained, Thomas gains no particular insight from the encounter, but once again his mind is being stretched by someone who, like the madmen he meets, like the John Doe Zen master he is about to encounter, does not fit neatly into the neat and tidy disarray of the medical establishment and the psychiatric institution.

What is Suler doing with his iconoclastic madmen? As they challenge Thomas, they also challenge the reader. We are drawn into Thomas’s confusion through their taking him seriously by dragging him away from scientism and rationality into new potential, new possibility. The rational is not sane, and the irrational is not crazy.

The angry debates and jockeying for power that the hospital staff are much given to form the backdrop for Thomas’s musings on what is effective psychotherapy, what is of value. During the discussion period of Rounds the staff routinely use defenses like projection, warding off their own self-doubt by criticizing each other. Thomas takes the argument outside of the hospital into the wider intellectual world, chronicling the rivalry between orthodox medical psychoanalysis and psychology, the once megalithic medical establishment meeting its match in the “Goliath” of the American Psychological Association. Again, early on Thomas cites Freud as saying that physicians are probably the least qualified to practice psychoanalysis, and that those immersed in liberal arts “resonate better with the psychological, emotional, and interpersonal issues that make up psychoanalysis.” (p. 20). Suler’s holy madmen may have more in common with the humanistic tradition from which certain psychoanalysts are drawn than the bickering staff of the mental hospital. But then again, given any sort of hierarchy, who wouldn’t bicker? After all the self itself is divided, the superego nags, the id insistently demands, and the ego perseverates. Thomas is in constant conflict, constant turmoil.

Toward the end of the novel Thomas and his colleagues engage in a spirited discussion of John Doe’s mental state, his “diagnosis,” veering giddily and excitingly from a psychoanalytic “Theory of Everything” drawn from Freud’s “Project” to cultural relativism to function versus subjective experience. Does functioning well in society mean mental health? Or does feeling at peace with oneself mean mental health? Can one be high functioning but miserable, or minimally functioning but fulfilled? Are Suler’s holy madmen, brilliant former philosophy student Jon the security guard and John Doe the amnesiac homeless man actually pictures of mental health because they are fulfilled and at peace with themselves?

Thomas asks himself, why not be a fiction writer? “After all, writers are next of kin to us psychologists.” (p. 216). He then speculates that characters in a novel are extensions of the novelists’ personality. “The creator always leaves his imprint on the created.” “Maybe, when combined, all the characters in a book make up one personality.” (p. 217). Suler has Thomas explicate a well-known theory that writers (like all artists) use their fantasy lives to try to heal themselves. Is Suler forestalling criticism, or stealing the thunder of wise guy critics who would attribute such motive to Suler the writer? If so, more power to Suler. He takes charge of his fictional reality, he owns his own fantasy, and he gives voice to that which all of us believe, that our most creative acts are fantasy fulfillments, that our creativity is the craziest and sanest part of ourselves, and cannot be separated from who we are in our core. We make up ourselves, we make up the world, and we encounter the reality of others’ fantasies, as our worlds collide, and occasionally, harmonize in the music of the spheres.

This is a most dramatic, engrossing, and intellectually engaging novel. Suler makes the challenges of beginning work as a psychotherapist, particularly with a difficult and demanding population, fascinating and recognizable. The story line moves apace, we identify with Thomas, who is both lost soul and seeker of the holy grail, and the intellectual debates are important and cogent. I hope Suler, and his alter ego Thomas, both write more fiction. I hope Thomas renews his journal writing, and Suler continues to teach not only with his academic writing, but with his fiction. Suler intends Madman to be not only a novel, but an instruction manual for psychology students. A teaching guide is available from True Center Publishing.

CODA: The day I began writing this review, I came upon an essay by Rivka Galchen in the New York Times Book Review of Sunday, June 27, 2010, “Pleasure Island,” about my all-time favorite writer, Jorge Luis Borges. She writes,

….Borges quotes from an essay by [Robert Louis] Stevenson that

makes the rather Borgesian claim that a book’s characters are

only a string of words. “Blasphemous as this may sound to us,”

Borges comments, “Achilles and Peer Gynt, Robinson Crusoe and

Don Quixote, may be reduced to it.” Borges then adds: “The

powerful men who ruled the earth, as well: Alexander is one string

of words, Attila another.”

Thomas Holden may be a string of words, but perhaps when we resonate with a string of words even if they are “only a string of words,” they are more than that as well. The moral integrity and emotional intensity of the string of words that John Suler put together to name and create Thomas Holden expresses the passion and beauty and anxiety of the quest for meaning and individuality committed psychotherapists experience and share with the people who they encounter in the transitional space that is the therapeutic experience. And as we do not ask of the baby, “Did you create the transitional object,” as we do not separate the reality of the frayed, chewed up blankie from the fantasy creation, we do not need to separate the reality of the individual letters T-h-o-m-a-s H-o-l-d-e-n from the compelling, believable character. Nor do we need to separate the fictional character from the autobiographical memories of John Suler. We are and are not madmen when we believe in Tinker Bell and Thomas Holden.